Top 10 HIV/AIDS-Related Clinical Developments of 2011

10. What Can We Expect After Test and Treat?

We have shifted into test-and-treat mode to rein in HIV (see above). The idea is that finding those with HIV will then allow for counseling and the prescription of ART, which in turn will reduce the risk of secondary HIV transmission. However, there are a number of Achilles' heels along the sequences of events from positive test to durably suppressed viral replication. So, while test and treat has in itself become a viral concept, the good things that are to follow are assumed, rather than assured. After all the testing and treating is done, what really happens?

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In an interesting amalgam of a paper that includes literature review, data mining and modeling, Edward Gardner and colleagues look at engagement in HIV care, how well we do and how we can do better at keeping viral loads undetectable.18 Critical to the test-and-treat strategy's effectiveness is the engagement of HIV-positive persons in care long term. Only with continued monitoring of ART and the reinforcement that accompanies clinic attendance can we expect viremia to be suppressed.

Using data from disparate sources, the investigators derive an estimate of the proportion of HIV-positive people in the U.S. with an undetectable level of plasma HIV viral load -- a sorry 19 percent. As Joep Lange in an accompanying editorial states, this is a shocking figure given we are 15 years into the era of highly active antiretroviral therapy, the last four of which saw a well-tolerated, one-pill, once-daily treatment option.

In what may become an enduring figure, the paper illustrates the lost opportunities in graphic form.

Failure to diagnose, failure to link to care, failure to retain in care, failure to provide ART, and failure to take ART all conspire to whittle down the number achieving suppression.

Sobering are the simulations that the investigators perform that suggest it will not be easy to increase the proportion of HIV-positive people in the U.S. that have undetectable HIV-RNA levels. Simply increasing the proportion of infected individuals who are aware they are HIV positive to 90 percent would increase the rate of being undetectable to only 22 percent. Engaging in care 90 percent of those currently aware they are HIV positive raises the figure to 34 percent. Assuming 90 percent of HIV-positive patients receive ART has minimal effect; similarly assuming 90 percent of patients on ART are undetectable has little impact. It is only by combining interventions so that 90 percent of HIV-positive individuals know their diagnosis, 90 percent of them engage in HIV care, 90 percent receive ART, and 90 percent achieve an undetectable viral load that we can expect a much more reasonable 65 percent of infected persons to have an undetectable HIV viral load.

The Bottom Line

The derived estimates and simulations used in this paper are somewhat simplistic, but they are likely not far off the mark. A similar analysis, published by the CDC in the Morbidity and Mortality Weekly Report (MMWR) for World AIDS Day, estimates that 28 percent of those infected are undetectable. Either way, these data indicate that testing and treating alone are not the complete answer to the question of how do we stop HIV in its tracks. We are armed with potent HIV therapies and we have a comprehensive health care apparatus for getting most HIV-positive people ART. Yet, we have not fully realized the potential of either.

Expanded testing makes sense on many levels. New guideline recommendations that expand ART to those with higher CD4+ cell counts and growing awareness of the public health benefits of ART are likely to boost the numbers of people with HIV who are prescribed ART (provided AIDS Drug Assistance Programs can continue to provide ART for the middle class and the poor). Therapies are becoming easier to take and that can help with adherence. Therefore, the stars are aligned for our getting better control of HIV on a population level and for the test-and-treat story to have a happy ending.

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